Provider Demographics
NPI:1982836391
Name:BACK DOOR, LLC
Entity Type:Organization
Organization Name:BACK DOOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUSS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:239-745-5917
Mailing Address - Street 1:1639 CAPE CORAL PKWY E STE 211
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-9657
Mailing Address - Country:US
Mailing Address - Phone:239-745-5917
Mailing Address - Fax:866-676-2762
Practice Address - Street 1:1639 CAPE CORAL PKWY E STE 211
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-9657
Practice Address - Country:US
Practice Address - Phone:239-745-5917
Practice Address - Fax:866-676-2762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100060103TP0016X
FLSW80391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF41439Medicare UPIN